Obesity Treatment: How to make a difference with your clients

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Obesity Treatment How to make a difference with
your clients

• Claudette Peck, LCMHC, RD, LD
• Staff Nutritionist
• Dartmouth College Health Service

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Obesity Trends Among U.S. AdultsBRFSS, 1991-2002
(BMI 30, or 30 lbs overweight for 5 4 woman)
2002
No Data lt10 1014 1519
2024 25
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2007 Obesity Map

ltprevious nextgt play stop                                                                                                                                                                                                                                                                                                               
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What are we dealing with?

• 2/3 of Americans meet the criteria for
  overweight (BMIgt25)
• Risks Combination of BMI and waist
  circumference
• Males gt40 inches
• Womengt35 inches
• Disease risks significantly increase with
  combination of BMIgt25,gt30, gt35, gt40

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Risk of Associated Disease According to BMI and Waist Size Risk of Associated Disease According to BMI and Waist Size Risk of Associated Disease According to BMI and Waist Size Risk of Associated Disease According to BMI and Waist Size
BMI   Waist less than or equal to40 in. (men) or35 in. (women) Waist greater than40 in. (men) or35 in. (women)
18.5 or less Underweight -- N/A
18.5 - 24.9 Normal -- N/A
25.0 - 29.9 Overweight Increased High
30.0 - 34.9 Obese High Very High
35.0 - 39.9 Obese Very High Very High
40 or greater Extremely Obese Extremely High Extremely High

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Assessment Factors

• Weight/BMI
• Waist Circumference Mengt40 inches, Womengt35
  inches
• Blood pressure gt130/85mm Hg
• Fasting glucose gt110 mg/dL
• Triglycerides gt150mg/dL
• HDL Men lt40mg,dL Women lt50 mg/dL
• Any 3 of the above Metabolic Syndrome
• Other risks Cigarette smoking, Age, Gender,
  Family History

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Genes vs. Environment

• Genetics loads the gunthe environment pulls the
  trigger.

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Influences on Food Intake

• Social pressure to eat
• Holidays Special Events
• Marketing/Advertisements
• Time of Day
• Paired eating activities
• Emotions
• Others

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Implications for improving effectiveness of
Interventions

• Study by Ogden (2000) showed weight loss
  maintainers(gt3 years of maintenance weight) when
  speaking of reasons for weight loss motivation,
  less endorsed medical reasons, more endorsed
  psychological consequences and indicated they had
  been motivated to lose weight for psychological
  reasons.

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Anti-Fat Beliefs

• Clear discrimination has been documented in 3
  areas education, health care and employment.
• The reason for this appears to be very strong
  anti-fat attitudes.
• For example, 28 of teachers in one study said
  that becoming obese is the worst thing that can
  happen to a person 24 of nurses said they are
  'repulsed' by obese persons and, controlling for
  income and grades, parents provide less college
  support for their overweight children than for
  their thin children.

Brownell, K., Puhl, R. (2003). Stigma and
Discrimination in Weight Management and Obesity,
The Permanente Journal, Summer 2003/7 (3)
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Obesity Bias What are your beliefs?

• Attitudes Toward Obese Persons scale (ATOP)
• Beliefs about Obese Persons scale (BAOP)
• Implicit Attitudes Test (IAT)

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How do other providers feel about the Obese?

• Primary care physicians report that key barriers
  to weight loss counseling are
• Self perceived low competence in treating obesity
• Lack of treatment effectiveness
• Poor patient motivation
• Time constraints
• Lack of reimbursement
• Befort, CA, et al (2006) Weight-Related
  perceptions among patients and physicians. J.
  Gen Intern Med, 21 (1086-1090).

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Additionally

• In a study of 620 primary care physicians, 40
  agreed that obese patients could reach a normal
  weight if they were motivated, but that most
  patients would not be motivated enough to lose a
  significant amount of weight.

Befort, CA, et al (2006) Weight-Related
perceptions among patients and physicians. J.Gen
Intern Med, 21(1086-1090).
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Motivation
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Motivational Interviewing (MI)

• MI emphasizes the identification of differences
  between a clients current behavior and his/her
  desired goals.
• MI acknowledges ambivalence and resistance as
  part of the process vs. a lack of motivation.
• MI requires the helper to be reflective vs.
  directive.
• DiLillo, V., Siegfried, N.J., West, D.S.
  (2003). Incorporating motivational interviewing
  into behavioral obesity treatment. Cognitive and
  Behavioral Practice, 10, 120-130.

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Importance/Confidence Scale

• How important is it for you right now to change
  your behaviors?
• On a scale of 0-10 what number would you give
  yourself?
• 0.10
• Not at all important extremely important
• What would need to happen for you to go from x
  to y?

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Importance/Confidence Scale

• If you decide to change, how confident are you
  that you could do it?
• On a scale of 0-10 what number would you give
  yourself?
• 010
• Not at all confident extremely confident
• What would need to happen for you to go from
• x to y?

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Termination
Maintenance
Relapse
Contemplation
Action
Preparation
Precontemplation
Transtheoretical Stages of Change
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Where to go from here

• If a client answers either question between 1-4,
  assume they are in pre-contemplation and consider
  the following steps
• Validate their experience
• Acknowledge the clients control of decision
• Give your opinion on the medical benefits of
  weight loss
• Explore concerns from the clients view
• Acknowledge possible feelings of being pressured
  to change
• Validate that they are not ready and that it is
  solely their decision
• State that, at this time they are not ready, but
  that it is possible they may feel differently at
  a future time.

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Where to go from here (cont)

• Answers between 5-7 indicate some continued
  ambivalence, assume clients are in contemplation.
• Validate clients experience
• Restate that the decision to change is still
  completely their own
• Clarify pros and cons of changing behavior
• Leave opportunity for continued movement toward
  change.

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Where to go from here (contd)

• If answers are between 8-10, assume they are
  ready to take action and help prepare them for
  behavior change.
• Praise decision to change behavior
• Identify and assist in problem solving regarding
  obstacles
• Encourage small initial steps
• Help identify social supports
• Provide future follow-up appointments to assist
  with adherence

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Diets vs. Non-Diet Approach
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Dietary Recommendations

• Kcal restrictions-1200-1500/day to promote weight
  loss
• Low carb-more weight loss in short-term no
  difference in losses long-term
• Meal replacements-may be helpful in LCD, may help
  to alter appetite expectations
• Fat, Fiber, and Protein all shown to be helpful
  in satiety. Protein especially important in
  maintaining lean body tissue during weight loss
• Nutrient distribution seems less important to
  overall kcal reduction

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The Bottom Line

• Reduced-calorie diets result in clinically
  meaningful weight loss regardless of which
  macronutrient they emphasize.
• Sacks, F. M., Bray, G. A., Carey, V. J., et
  al.,(2009). Comparison of weight-loss diets with
  different compositions of fat, protein, and
  carbohydrates. NEJM, 360(9), 859-873.

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Realistic and Reasonable Goals for weight loss

• 8-10 reduction in weight in first 6 months
• Most weight loss occurs in first 12 weeks of
  program
• Secondary goal To sustain momentum and maintain
  weight loss

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Discrepancies in Expectations
Patients beliefs Physicians beliefs Clinical guidelines
Expected weight loss goals Expected weight loss goals Expected weight loss goals
24-38 loss of initial weight 14 loss of initial weight 10 loss of initial weight
Befort, CA, et al (2006) Weight-Related
perceptions among patients and physicians. J.Gen
Intern Med, 21(1086-1090).
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Improving Adherence

• Attendance at group sessions strongly predicted
  weight loss. Several recent trials have shown
  that continued contact with participants after
  weight loss is associated with less regain.
  These findings together point to behavioral
  factors rather than macronutrient metabolism as
  the main influences on weight loss.
• Sacks, F. M., Bray, G. A., Carey, V. J., et
  al.,(2009). Comparison of weight-loss diets with
  different compositions of fat, protein, and
  carbohydrates. NEJM, 360(9), 859-873.

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Fit vs. Fat Can you be both?

• Overweight and obese people who are fit are less
  likely to die prematurely than unfit people who
  are lean (Lee, CD, et al., Am J Clin Nutr 1999
  69373-380)
• Highly Fit men with 2 or 3 risk factors had about
  the same mortality risk as Low Fit men with no
  risk (Blair, SN, et al., JAMA 1996 276 205-210)
• Low Fitness is as significant a risk factor for
  premature death as smoking, high blood pressure,
  diabetes, and high blood cholesterol, regardless
  of weight ( Barlow et al., Int J Obes Metab
  Disord, 19(suppl 4)41, 1995 and Wei et al.,
  JAMA, 282 1547, 1999)

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Where does exercise fit into weight loss planning?
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Physical Activity (PA)

• PA prevents weight gain
• PA enhances weight loss
• PA is the best predictor of weight loss
  maintenance.
• Ultimate goal in behavioral interventions is to
  promote long term adherence

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Determining Exercise Needs

• Research shows that approximately 4.5 hours of
  moderate intensity exercise (55-69 max HR) that
  results in an energy expenditure of at least 2000
  calories per week, in combination with a reduced
  caloric intake, will produce desirable results.
• Intermittent exercise (10-15 minutes sessions)
  that accumulate to 30-40 minutes per day, seems
  to be as effective as continuous sessions.
• Start slowly

American College of Sports Medicine
www.acsm.org
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Lifestyle Activities

• Short bout exercise (10 minute intervals of
  moderate activity) practiced multiple times per
  day shown to have better adherence in meeting
  exercise goals, with similar level of fitness.

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What works? Answers from National Weight
Control Registry

• How the weight loss was accomplished 45 of
  registry participants lost the weight on their
  own and the other 55 lost weight with the help
  of some type of program.
• 98 of Registry participants report that they
  modified their food intake in some way to lose
  weight.
• 94 increased their physical activity, with the
  most frequently reported form of activity being
  walking.
• There is variety in how NWCR members keep the
  weight off. Most report continuing to maintain a
  low calorie, low fat diet and doing high levels
  of activity.
• 78 eat breakfast every day.
• 75 weigh themselves at least once a week.
• 62 watch less than 10 hours of TV per week.
• 90 exercise, on average, about 1 hour per day

http//www.nwcr.ws/Research/default.htm
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Behavioral Recommendations

• Accountability Food Monitoring, Weight
  Monitoring
• SMART goals (Specific, Measurable, Appropriate,
  Reasonable, Timely)
• Non-diet Approach
• Support

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Food Diary Name _________________________________
__ Date ____________________Today is Su M
Tu W Th F Sa
Food or Drink (Description/Amount) Time Hunger Level Where? With Whom Doing What Feelings/Mood Fullness After Eating Physical Activity B/P


Starved

Very Hungry

Hungry

Slightly Hungry

Hunger-Fullness Scale
Slightly Full

Balanced
Full
0 1 2 3 4 5
6 7 8 9 10

Very Full
STARVED
STUFFED
H-U-N-G-E-R
COMFORT/NEUTRAL
F-U-L-L-N-E-S-S

Stuffed
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When diet and exercise arent enough
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Hebals/Medications

• Medication may be indicated in cases where
  BMIgt30, and diet, behavior and exercise are
  already being used.
• For medication to cause weight loss, it must
  Reduce energy consumption, OR Increase energy
  expenditure, Or Interfere with energy absorption

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Herbal/Medication Options

• No current herbal/supplement on the market
  appears to provide safe and effective use for
  weight loss. Most herbals or natural products
  are either nervous system stimulants (caffeine or
  other derivatives), or bulking agents (fibers).
• Orlistat (Xenical) approved for long-term use
  (interferes with fat absorption reducing about
  30 of fat consumed) Alli (over-the-counter)
  lower-dose Orlistat
• Sibutramine (Meridia) approved for long-term use
  (reduces energy consumption by suppressing the
  appetite) Peak concentration 6-7 hours, suggest
  client take about 6-7 hours prior to most
  vulnerable eating time. Should be cautious with
  patients with HTN, in which monitoring should
  occur routinely.

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Medication Costs/Benefits

• Medication can pose a financial burden to client
• With use of Orlistat or Sibutramine, studies are
  indicating an additional 5-10 reduction in total
  weight as compared to diet alone.

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What are the surgical options?

• Restrictive procedures have more flexible
  criteria as they are both adjustable and
  reversible.
• Bypass surgery criteria are
• BMIgt40
• OR BMIgt35 with comorbidities

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Surgical Options

• Options RestrictiveVertical Banded
  Gastroplasty (VBG) and Lap Band (no malabsorption
  for either of these) Restricts gastric volume
• Restrictive and MalabsorptiveRoux-en Y Gastric
  Bypass and Distal Roux-en Y Gastric Bypass
  (restricts gastric volume AND bypasses the
  duodenum and part of jejunum, causing decrease in
  absorption of calories)
• Possible Outcomes-
• Restrictive procedures show 15-20 loss of
  actual weight, Bypass procedures show 25-30 loss
  of actual weight. Most losses occur within first
  6 months post-surgically.

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Things that can make the difference

• Provide a receptive environment including gowns,
  tables, chairs, scales and cuffs that will fit
  this clientele
• Improving adherence by nurturing the clients
  motivation, assisting in developing specific
  behavioral changes. Develop a relationship with
  your client.
• Understanding ambivalence and resistance when
  working with your client vs. judging their
  motives.
• Be Aware of biases and attitudes
• In a study done by Maiman et al., J Amer Diet
  Assoc., 1979 87 of dietitians viewed the obese
  as self-indulgent, 74 attributed family
  problems to the obese, and 32 indicated that
  obese patients lack willpower.

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Case Study 1

• 43 y.o. female, single-mother of 3 children (ages
  15, 13, 8), works full-time. Ht 54, weight 186
  lbs. Family hx of DM type II, HTN.
  Pre-pregnancy weight was 135 lbs, gained weight
  with each pregnancy, but unsuccessful in taking
  it off. Complains of fatigue and feeling
  stressed with work, home and responsibilities.
  States, I know that losing weight will help me
  have more energy and feel better about myself,
  but the idea of making changes seems overwhelming
  at this point.
• Where do you believe she is in terms of stage of
  change?
• What else do you need to know?
• What questions will you ask?
• Describe the conversation you may/may not have
  with her?

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Comments/Questions?
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Food Intake Patterns
Kcals 1400 1600 1800 2000 2200 2400 2600 2800
Fruit 1.5 c 1.5 c 1.5 c 2 c 2 c 2 c 2 c 2.5 c
Veg 1.5 c 2 c 2.5 c 2.5 c 3 c 3 c 3.5 c 3.5 c
Grain 5 oz 5 oz 6 oz 6 oz 7 oz 8 oz 9 oz 10 oz
Meat/Beans 4 oz 5 oz 5 oz 5.5 oz 6 oz 6.5 oz 6.5 oz 7 oz
Milk 2 c 3 c 3 c 3 c 3 c 3 c 3 c 3 c
Oils 4 tsp 5 tsp 5 tsp 6 tsp 6 tsp 7 tsp 8 tsp 8 tsp
Extra kcals 171 182 195 267 290 362 410 426
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Serving Sizes Everyday Objects
1 cup of cereal a fist                      
1/2 cup of cooked rice, pasta, or potato 1/2 baseball                      
1 baked potato a fist                      
1 medium fruit a baseball                      
1/2 cup of fresh fruit 1/2 baseball                      
1 1/2 ounces of low-fat or fat-free cheese 4 stacked dice                            
1/2 cup of ice cream 1/2 baseball                      
2 tablespoons of peanut butter a ping-pong ball                      
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References and Websites

• National Institutes of Health Publication No
  02-4084. The Practical Guide Identification,
  Evaluation, and Treatment of overweight and
  obesity in adults
• http//win.niddk.nih.gov/index.htm
• www.obesity.org
• www.eatright.org
• www.consumer.gov/weightloss
• www.naaso.org
• www.shapeup.org

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Resources

• www.mypyramid.gov
• National Institutes of Health Publication No
  02-4084. The Practical Guide Identification,
  Evaluation, and Treatment of overweight and
  obesity in adults
• http//win.niddk.nih.gov/index.htm
• www.obesity.org
• www.eatright.org
• www.consumer.gov/weightloss
• www.naaso.org
• www.shapeup.org.
• www.nwcr.ws/Research/default.htm
• www.acsm.org
• www.thelifestylecompany.com/

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References

• Barlow, et al (1995). Int. J. of Obesity
  Related Metabolic disorders, 19 (supplement 4),
  41.
• Befort, C.A. et al (2006). J. General Internal
  Medicine, 21 (1086-1090).
• Blair, S. N., et al (1996). JAMA, 276, 205-210.
• Brownell, K. Puhl, R. (2003). The Permanente
  Journal, Summer (2003), 7,(3).
• cdc.gov/nccdphp/dnpa/obesity/trend
• DiLillo, V., Siegfried, N.J., West, D.S.
  (2003). Incorporating motivational interviewing
  into behavioral obesity treatment. Cognitive and
  Behavioral Practice, 10, 120-130.
• http//www.health.gov/dietaryguidelines/dga2005/do
  cument/default.htm
• Institute for Natural Resources. (2004). Weight
  Matters Obesity, hormones appetite. Table 9,
  pp 9-10.
• Lee, C. D., et al (1999). Am J Clin Nutr, 69,
  373-380.
• Ogden, J. (2000). Int. J of Obesity Related
  Metabolic disorders, 24 (8), 1018-1025.
• Prochaska, J. O., Norcross, J. C., DiClemente,
  C. C. (1994). Changing for Good. New York,
  Avon Books.
• Sacks, F.M., Bray, G.A., Carey, V. J. (2009).
  Comparison of weight-loss diets with different
  compositions of fat, protein, and carbohydrate.
  NEJM, 360(9). 859-873.
• www.nwcr.ws
• www.acsm.org
• www.aicr.org/press/NANAReport. (June 2000) From
  Wallet to Waistline The hidden costs of super
  sizing. The National Alliance for Nutrition and
  Activity (NANA).
• www.cellinteractive.com/ucla/physcian_ed/interview
  _alg.html